Friday, May 9, 2008

Health professionals talking about clinical practice on the Internet

I have been following a series of blog posts centered around the story of a birth told by a midwife in the UK. I do not want to go into much detail here because you can read the whole story on Dr Crippen's blog and a follow up comment on A Midwife's Muse. But the crux of the matter is the midwife relates the tale of a homebirth she 'managed' with details of some questionable decision-making and actions. Dr Crippen was so incensed that he reported the midwife to the UK Midwifery Council.

Reporting clinical stories on the InternetI don't want to get into a discussion about the wrongs and rights of the midwife's management. But I have found the whole story - the publishing of the story, the reply to it from various observers and ongoing online discussion - to be utterly fascinating from a professional and educational point of view. It is a very good example of how the Internet can turn bad on a number of accounts.

Privacy and confidentialityA major issue is the confidentiality or privacy of the client/patient. I have noticed a number of midwives publishing birth stories on the Internet, and some do not make it at all clear whether they have the woman's permission or not. And it certainly isn't clear if 'Sharon' and her husband had given their permission for this story to be published.

Health professionals have a number of legal and professional obligations and standards with regard to sharing client information, so it is vital that we adhere to them. The Internet is a very big, wide world in some respects, but in other respects it is a very small world and people can be identified a lot easier than one would think. Even if the woman in this story is happy to be identified, I wonder how she now feels about the ensuing publicity. What effect is it having on her state of mind at a time when she has enough to worry about having just had a new baby?

Professional online behaviorThe other issue is how we behave online as health professionals. Setting aside the stupidity of publishing a story of clinical actions and assessment that ends up getting reported for professional misconduct, the original post is very unprofessional in the way it is attacks colleagues. Even if the midwife had a basis for her complaints, there are far better ways of dealing with inter-professional conflict and difference of opinions than ranting on a web site.

Reflecting on clinical events on the InternetI'll be honest, this whole incident has caused me to think further about my stance on reflecting on my clinical practice in an online context. I have advocated that midwives are open and honest in their reflections of their clinical practice in an online environment, because it creates an opportunity for debate and shared learning. I probably still take this position but at the same time, this particular story really emphasizes the importance of being extremely careful about what you say on the Internet. Don't get me wrong, I am not advocating that one covers up one's clinical mistakes, but I certainly feel health professionals have to be careful about what they divulge online.

Being a role model I have talked about how I feel about being an online role model to students. I feel this is applicable to all health professionals who engage in online communication. We must remember that there are many eyes on us, including students. Do we really want students see us act in a very unprofessional and negative way as demonstrated in this story?

Ultimately, I think the sad thing about this whole story is that it has brought midwifery and home birth into disrepute. So please, everyone, think twice about what you publish on the Internet and how you respond to comments. Think about the profession you are representing and the effects of your online behavior on people like students and health consumers.

How do you feel about the issues that have been highlighted by this story?

19 comments:

Some good points Sarah - disinhibition can affect the best of us and we need to be careful what we say online. we can get so used to just typing something off and sending without reflection. Can be useful too in online posting about professional issues to check with peers about what we are putting out there.

I have to say that that was exactly what I was thinking, Howard. In this particular incident, I do think that peer review would have been extremely useful. Mind you, I'm one to talk - I am very quick to fire off an email or blog post about something I am passionate about. It is only later, once I have calmed down, that I review what I have written and realized the potential to be misconstrued. For the midwife involved (and not that I'm saying that she doesn't or does deserve it), her whole future has been threatened, which is a very serious matter.

This is a difficult one and is another example of having 'to cover our backs'. I have to admit that I never ask women if they have objections to my publishing experiences which may have involved them, as doing that would reveal that I blog and also mean that I would no longer be anonymous. I don't really consider myself to be a 'medical' blogger, more a diarist who happens to be a midwife, hence the diverse, often personal, nature of my entries. I would like to believe that when I muse on midwifery it may help people to understand all the elements of my job and to appreciate that most midwives try to provide the best care possible in circumstances which our sometimes beyond our control.Like you I will often comment or blog in the heat of the moment, we are human though and a long as we are not unprofessional or abusive I don't believe that honsty is something to regret.

This is a difficult one and is another example of having 'to cover our backs'. I have to admit that I never ask women if they have objections to my publishing experiences which may have involved them, as doing that would reveal that I blog and also mean that I would no longer be anonymous. I don't really consider myself to be a 'medical' blogger, more a diarist who happens to be a midwife, hence the diverse, often personal, nature of my entries. I would like to believe that when I muse on midwifery it may help people to understand all the elements of my job and to appreciate that most midwives try to provide the best care possible in circumstances which our sometimes beyond our control.Like you I will often comment or blog in the heat of the moment, we are human though and a long as we are not unprofessional or abusive I don't believe that honsty is something to regret.

Thanks for replying to this - it is good to hear the views of another midwife.

This is an extreme case so it is probably important not to take a knee-jerk reaction. What made me write this post was discussions I was having about students' use of the Internet for reflection. And I was thinking that if they see unprofessional online behavior by midwives and health professionals, that is not going to help them develop good practice. So I would encourage students to reflect in a closed environment until they were mature enough in their practice to be able to pull out the issues of open reflection.

Ultimately I agree with you & this story probably won't make any difference to the way I am open about my practice. I am human - I do make mistakes and I happy to talk about them here because my blog is about my learning, encouraging debate and sharing my learning.

well I have to admit until I read Dr Crippons blog - I really thought this whole business about online manners and etiquette - and commenting techniques was all a bit precious and OTT - harden up I thought! I really didn't appreciate the spectrum of comments that was out there - or how out of hand things can become when there is no boundary. That page is completely out of control and hysterical. Its hateful and abusive and totally unprofessional. Now that I have seen this really bad eg of nasty on line commentary - I take your point. It takes all sorts!

Yes, I don't think I made it clear in my post that I was not only talking about the behavior of the midwife in the first instance but I was also disgusted with the comments and behavior that followed. There's no constructive learning going on there.

The abusive comments which were left on Dr C's entry are something that I only see on his blog, previous 'madwife'and 'quacktitioner' posts have produced similar foul-languaged responses. What I find disturbing is the way health professionals from different disciplines will pit themselves against each other and deride the others intelligence etc., and the public are reading this.When I read the entry I was furious with the midwife for exposing her profession to the critical eye of the Amy Tuturs of this world and giving them ammunition against planned homebirth and midwives. I believe my response was to attempt to demonstrate that not all midwives take risks, not that I would be able to anyway in the tightly controlled regime of NHS homebirth! The problem is that the public read stories like this and believe that all midwives function in the same way.

I agree, midwifemuse. What an individual midwife does in her own practice is up to her. If she ends up being disciplined, so be it. As you say, there are plenty of people waiting to pick off midwives. Why would we want to give them ammunition? The vast majority of us work very hard in very difficult circumstances. We give more than 100% to women and their families. Often to the detriment of our own families. Please... let's all behave in a professional manner remember that our actions - real and virtual - impact not only on ourselves but also on the profession, nationally,and globally.

At the same time, how is much is said to be contentious and gain readership. Probably the best thing we can do is ignore the likes of Dr Crippen and Dr Tuteur. They are sensationalists. I am sure that the public knows that the average midwife works really hard to get the best possible outcome for the woman. If we didn't care about women, we'd be off doing a job that gives us a lot more money and kudos.

You can't bury your head in the sand about the internet. Comment is free and uncensored out here. Taking the perceived but misjudged moral high ground attitude of not deigning to comment about clinical matters on the internet does your profession a disservice. The madwives are out there selling their wares. You need to stand up and be counted.

well you have convinced me john. Having seen what you have to offer compared with a midwife - I would not come near you - and I would not expose my family or baby to the environment you offer either. You seem aggressive and obsessive and I can only imagine how this plays out in the "care" you provide. No thanks.

"When I read the entry I was furious with the midwife for exposing her profession to the critical eye of the Amy Tuturs of this world and giving them ammunition against planned homebirth and midwives."

That's demonstrates rather skewed priorities. Isn't the problem that the midwife exposed the PATIENT needlessly to an increased risk of harm? Shouldn't women and babies be the primary priority of midwives, not protecting the reputation of midwifery?

Sarah Stewart:

"Probably the best thing we can do is ignore the likes of Dr Crippen and Dr Tuteur."

If you exposed what you felt were unsafe practices in obstetrics would you admire doctors who said, "Probably the best thing we can do is ignore the midwives who offer criticisms of our actions"? Do you really think that the appropriate reponse to professional criticism is to ignore it?

The problem is that this is a leading independent midwifery practice and they have demonstrated the mindset that this kind of management is something to be proud of and something aspirational eg. we can do it on our own, and to heck with the risks.

I'm glad it's been exposed, for ever available in the google cache. This kind of thinking is widespread & poisons independent midwifery. The sooner they become responsible and start thinking about consequences rather than dogmatic gender & anti-hierarchical politics is when they will gain respect among other professionals.

Why is that even the hospital midwives regard them with disdain?

A first start will be saying to some patients, "actually you're high risk and you should deliver in hospital" and forgoing their massive fee.

Amy Tuteur (apologies for the previous mis-spelling)‘That's demonstrates rather skewed priorities. Isn't the problem that the midwife exposed the PATIENT needlessly to an increased risk of harm? Shouldn't women and babies be the primary priority of midwives, not protecting the reputation of midwifery?’If you only read that paragraph, yes, it could be construed as skewed priorities. However, I then go on to say that the reason I was furious about Sharon’s Story was that it could paint all homebirth midwives in a poor light and that we don’t all take risks, the risk being the outcome for Mother and/or baby. In my mind the avoidance of proven risk is of prime importance and so is implicit.

I am afraid Sarah I do not find all this story fasinating I find it all quite disturbing that we are moving into the public forum to play judge and jury. This seems to be the current trend, jury by the media and the internet. This story is certainly generating comments. It is interesting to read Dr John's comment, you are sensible when you agree with him, however when you do not 'you have to stand up and be counted'Yes 'comments are free and uncensored' but we are all professional and I thought there was such a thing as common courtesy, but alas I think that is a thing of the past. I can not help but think this has turned into one of those horrible myspace bullying stories you hear of. As for confidentiality or privacy there is none and maybe it is time to reflect on the ANMC Code of Conduct and our responsibilites of confidentiality.I really would like to see more collaboration with our medical colleagues rather than this ulgy bantering, it is time to work together.

Sarah Stewart

Welcome to my blog which is a mix of talk about stuff that takes my fancy. My views are my own and not necessarily of my employer, the Australian College of Midwives. I am always really interested to hear your thoughts and feedback, so please feel free to leave a comment at any time.